Moderate Skin Laxity Research Articles

A Modified Subbrow Blepharoplasty for Correction of Severe Upper Eyelid Skin Laxity.

Periorbital aging is characterized by dermatochalasis, lateral hooding and malformation of multiple eyelid creases. Rejuvenation of periorbital region is of great concern in aging Asians, especially for the females. However, the conventional subbrow blepharoplasty was indicated for mild or moderate skin laxity. For severe laxity, double-eyelid incision is necessarily to be involved. This study aims to improve the severe upper eyelid dermatochalasis through an extended subbrow single-incision approach with desirable outcomes. Patients underwent this surgical method from October 2020 to April 2022 were retrospectively reviewed. The redundant skin and orbicularisoculimuscle were excised through a spindle-like subbrow incision delicately designed in the sitting position. Surgical outcomes were evaluated by heights of designed line from the palpebral margin to the pupil center (HPPC), medial cornea (HPMC), and lateral canthus (HPLC) at different follow-ups. The overall satisfaction score of cosmetic outcomes was assessed by an independent surgeon and patients themselves based on the evaluation of: subbrow scar, eyelid symmetry, lateral hooding lifting, visual block improvement and brow shape. A total of 75 cases were reviewed, including 3 men and 72 women. The preoperative HPPC, HPMC, and HPLC were 4.27 ± 0.40, 4.72 ± 0.45 and 3.41 ± 0.35 mm. The values were postoperatively improved to 7.01 ± 0.46, 6.57 ± 0.34 and 5.69 ± 0.26 mm, respectively, presenting significantly different (p<0.05). The mean surgeon satisfaction scores were 3.6 ± 0.6 (range, 2.0-4.0), and patient satisfaction scores were 3.5 ± 0.6 (range, 2.0-4.0). No hypertrophic scar, sunken upper eyelids or other complications was found. The modified subbrow blepharoplasty method is an effective and safe alternative for correcting severe upper eyelid skin laxity, which can achieve both good cosmetic outcomes and functional improvement. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Vectorized facial skin tightening: A study on the Thermal Thread Technique™ utilizing high-intensity, high-frequency, parallel ultrasound beam.

Facial skin tightening with wrinkle/fine line reduction is a highly demanded procedure in the aesthetic field. Although there are studies focused on the types of energy sources, the total amount of thermal energy, and the affected depth, there have been no reports examining the relationship between the shape of thermal energy and the directivity of skin tightening. We have developed a specific method to apply thermal energy to the dermis in continuous parallel lines, resembling a thread, perpendicular to the Relaxed Skin Tension Lines (RSTL) for vectorized collagen contraction using synchronous ultrasound parallel beam technology. To evaluate the safety, tightening capability, and directivity of the Thermal Thread Technique™ utilizing a high-intensity, high-frequency, parallel ultrasound beam. A total of 34 cases, both males and females aged between 30 and 70 years with Fitzpatrick skin types 2-4, exhibiting mild to moderate skin laxity, participated. All subjects received one treatment using the Thermal Thread Technique™ utilizing high-intensity, high-frequency parallel ultrasound beam to cover the full face and submental area. 3D clinical images were captured before, 8 weeks, and 24 weeks after the treatment. A quantitative image analysis of captured 3D images was performed to objectively measure the direction and distance of contraction. The average contraction distance from baseline (0 mm) to 8 weeks and 24 weeks posttreatment were 1.91 ± 0.61 mm (p < 0.001) and 1.96 ± 0.67 mm (p < 0.001) respectively. Regarding the contraction direction at 24 weeks posttreatment, the angle formed between the contraction direction and the base axis, which is perpendicular to the RSTL, was + 9.85° ± 32.94°. Out of 34 cases, 28 met the criteria with the angle within ±22.5° of the base axis (p < 0.001). The average pain score on a 0-5 scale (0 being no pain, and 5 being maximum pain) was 2.63 ± 0.78. No side effects were reported during the treatment or observation period. The Thermal Thread Technique™ utilizing a high-intensity, high-frequency, parallel ultrasound beam was proven to be clinically safe and effective for vectorized facial skin tightening.

Endoscopic, "Scarless" Composite Flap Face and Necklift.

Deep-plane or composite flap facelift techniques allow deep structural rejuvenation of the face by release of retaining ligaments in the sub-SMAS plane with elevation and fixation of the SMAS/platysma/skin flap as a single, "en-bloc" unit. This means that in cases with mild to moderate skin laxity, the preauricular incision serves the purpose of access only. The author therefore developed an endoscopic-assisted, en-bloc composite flap face and necklift without a preauricular incision. The technique uses the prezygomatic and premasseteric (facial) and subplatysmal (neck) spaces as ideal optical cavities for endoscopic dissection and ligament release. Verticalization of fixation vectors and modified concho-mastoid traction sutures are used to minimize preauricular skin reduncancy. The surgical procedure is described in detail. Clinical experience in 41 consecutive cases and comparison to other techniques with respect to relevant anatomy are also presented. This endoscopic en-bloc composite flap facelift technique consistently and safely produced results comparable to conventional, "open" composite flap facelifts done by the same surgeon on similar candidates during a prior period.

The Role of Subcutaneous Radiofrequency-Assisted Liposculpture in the Facial Plastic Surgeon's Practice.

Importance: Percutaneous radiofrequency-based skin tightening procedures can offer patients an option to undergo a potential treatment for skin laxity and excess adipose of the face and neck with less downtime, lower cost, and decreased risk of complications compared with more aggressive open procedures such as neck lift, face and neck lift, and platysmaplasty. Observations: FaceTite and AccuTite can safely yet effectively deliver energy into the subdermal space, targeting the dermal collagen network and deeper fascial layer. Ideal candidates have early jowl formation, mild to moderate skin laxity, and submental adiposity. Relevance & Conclusions: From the perspective of facial plastic surgeons, these procedures can enhance the volume of an aesthetic practice by welcoming patients who may not otherwise present for face and neck rejuvenation out of fear from surgery. Furthermore, many of these minimally invasive patients will ultimately return for surgical rejuvenation later in life.

Post-Bariatric Plastic Surgery: Abdominoplasty, the State of the Art in Body Contouring.

Due to the increased prevalence of obesity in the last decades, bariatric surgery has been on the rise in recent years. Bariatric surgery is a compelling option for weight loss in obese patients with severe obesity-related comorbidities or for whom lifestyle modifications have proven ineffective. Redundant skin following significant weight loss is a common occurrence affecting up to 96% of patients who undergo bariatric surgery, negatively impacting physical and psychosocial health and detracting from activities of daily living. Statistics of the American Society of Plastic Surgeons show that 46,577 body contouring procedures were performed after massive weight loss in the USA in a 2020 report. Abdominoplasty, a well-established cosmetic surgery procedure for improving body contour, is performed by removing excess skin and fat from the abdominal wall and thereby restoring musculofascial integrity and skin elasticity, resulting in a more ideal body shape and increasing quality of life. Although abdominoplasty is a safe procedure, it has been associated with a higher complication rate compared with other body-contouring procedures. Technologic advances over the past decade have been developed as non-invasive alternatives or adjunctive tools to surgery to enhance cosmetic results and minimize complications. New energy-based technologies may supplant invasive surgery for mild to moderate skin laxity and/or diminish the extent of surgery and resulting scars. Plastic surgeons play a significant role in improving the quality of life of patients who suffer from obesity and underwent bariatric surgery. We are deeply convinced, however, that the advancement of knowledge and research in this field will determine the introduction of new technologies and custom-made techniques. This advancement will reduce the complication rate with a rapid reintegration of the patient into the world of work and resumption of daily activities.

Temperature-Controlled Monopolar Radiofrequency in the Treatment of Submental Skin Laxity: A Prospective Study.

Laxity of the submental area is a common cosmetic complaint of the aging population. The aim of this study was to determine the safety and effectiveness of a temperature-controlled, minimally invasive percutaneous monopolar radiofrequency device to improve dermal laxity and achieve lift. A total of 72 subjects (35-65 years old) with mild to moderate skin laxity in the submental area were included in this single-center prospective study. All subjects received 1 treatment at baseline with an average subdermal temperature of 63°C. The primary endpoint was the proportion of subjects with at least a 20-mm2 decrease in surface area at Day 90 based on 3-dimensional photography. Secondary endpoints included skin elasticity measured by Cutometer, assessment by a blinded physician panel from 2-dimensional photographs, and physician- and subject-reported outcomes. At Day 90, 72.1% (95% CI: 62.2%-84.0%; P < 0.001) of subjects achieved at least a 20-mm2 lift of the submental area. All Cutometer-measured skin elasticity values (R2, R5, R7) showed significant improvement by 180 days. The independent panel graded 74.2% of subjects as "improved" at 90 days (95% CI: 62.0%-84.2%; P < 0.001). The treatment was well tolerated, and only 1 possibly related serious adverse event was reported (pharyngeal inflammation). Treatment with temperature-controlled monopolar radiofrequency alone is a safe and effective treatment to achieve submental lift for at least 6 months.

Bipolar Radiofrequency as an Adjunct to Face and Body Contouring: A 745-Patient Clinical Experience.

Radiofrequency (RF) technology has ushered in a new paradigm in body contouring for patients with mild to moderate skin laxity who desire fat removal without exacerbating skin laxity issues. A bipolar internal RF device, used as an adjunct to liposuction, has been found to be simpler and more accurate than previous technologies. The aim of this study was to review the authors' clinical experience with bipolar RF-assisted liposuction (RFAL). We conducted a review of our large experience with bipolar RFAL, evaluating the nuances from appropriate patient selection and specific treatment areas. The review covered 745 patients treated from January 2017 to January 2020 at 2 centers. A retrospective chart review was performed of the first and last 50 patients treated at each center (for a total of 100 patients in each group) to assess trends in outcomes and adverse events. Results were generally excellent from physician evaluation, and overall patient satisfaction was high (96%). The two most common adverse events were temporary swelling (9%) and nodules (8.5%). Selected examples of a variety of cases are reviewed. The ability to tighten skin with a minimally invasive tool adds much to the contemporary approach to the body-contouring patient with skin laxity. Adverse events were minimal and greatly decreased after an initial short learning curve. Bipolar RFAL is a strong addition to our surgical armamentarium and has become an essential tool for our practices.

Non-surgical skin tightening

Skin laxity is an unavoidable consequence of aging and chronic sun exposure. Patients are increasingly turning to non-surgical skin tightening measures for a more youthful look. Non-surgical methods can be effective in treating mild to moderate skin laxity, while offering decreased downtimes and fewer serious complications than surgical interventions. This article reviews the major non-surgical interventions for skin laxity: ablative and non-ablative lasers, radiofrequency, and microfocused ultrasound, noting their physiologic mechanism of actions, clinical benefits, and side effects. Regardless of the procedure, patient selection and expectation setting are crucial to achieving desired results and ensuring patient satisfaction.

Efficacy and safety of 1440-nm Nd:YAG laser on lower face and neck rejuvenation.

Reviewing the literatures, we did not found-to our knowledge-any study using the Nd:YAG laser with wavelength 1440nm in assisted liposuction and rejuvenation of the head and neck region although of the higher absorption rate for fat and water. Evidence-based practice supports the benefits of laser-assisted liposuction over conventional liposuction with skin tightening in selected areas specifically the submental area and the neck. The aim of the work is to evaluate the efficacy and safety of Nd:YAG laser wavelength (WL) 1440nm on lipolysis of submental area and skin tightening of the lower face and neck area. Fifty-seven patients with submental localized fat deposits and mild to moderate skin laxity were subjected to laser liposuction using Nd:YAG laser with WL 1440nm (SmartLipo Triplex)® device. The efficacy of skin laxity improvement was assessed together with the whole satisfaction rate for each patient. Overall satisfaction rate was 97% of the patients. One sample test regarding skin laxity showed significant improvement (34.6%) after 6months follow-up (0.268 SD p < 0.05) (Table 4). Complications included edema, soreness, weakness in the lower lip, and ecchymosis that resolved conservatively except one case that complained of seroma which needed aspiration and healed without infection. In conclusions, Nd:YAG laser with WL 1440nm can be used safely and effectively for submental-assisted liposuction and lower face and neck rejuvenation. Less laser energy was needed for lipolysis and skin tightening as the fat and water have a higher absorption rate at wavelength 1440nm.

Prospective Study on Clinical Efficacy and Safety of a Single Session of Microfocused Ultrasound With Visualization for Collagen Regeneration.

Recent studies have shown that transcutaneous microfocused ultrasound with visualization is beneficial for noninvasive skin tightening, collagen regeneration, and lower face contour improvement. The primary study endpoint was the improvement of the laxity and ptosis face skin; the secondary endpoint was the improvement of wrinkles, texture, and hemoglobin content; and the third endpoint was the patient's responses to a patient satisfaction questionnaire. Patients with soft to moderate skin laxity and ptosis of the face and neck were enrolled and their sex, ethnicity, age, Fitzpatrick skin type, and smoking habit recorded. Patient assessment was made by digital macro-photographs, Vectra H2, and Antera 3D, and strict exclusion criteria were set up. From November 2017 to November 2018, 47 women and 3 men with a mean age of 52.8 ± 7.43 years and Araco's Ptosis Scale System 2.7 ± 0.46, which fit the inclusion criteria, were enrolled in the study. All patients signed a consent form and received 1200 spot-lines (400 lines from each transducer) of microfocused ultrasound with visualization. No major side effects were reported during the study and all patients completed the follow-up after 6 months. Wrinkles, texture, Surgeon Assessment Scoring System scores, and patient satisfaction questionnaire scores improved significantly. Patients found the treatment tolerable according to the patient pain scale rate. No statistically significative differences were found among homogenous groups of smokers and nonsmokers. The study proves that microfocused ultrasound with visualization in a single session of treatment in monotherapy is safe and effective for the treatment of face laxity and ptosis when a proper number of energy spot-lines is delivered in the correct tissue layer.

Comparative Study between Circum-areolar Skin Reduction and Standard Long Scar Techniques for Treatment of Severe Degrees of Gynaecomastia after Massive Weight Loss

Background: Reshaping of the male chest following massive weight loss is challenging and there are many techniques for its management. Aim: This study was to compare circum-areolar skin reduction for the treatment of severe gynaecomastia in massive weight loss patients with other standard long scar techniques. Patients and methods: Patients with massive weight loss whom their redundant and ptosed breast and patients whom their weight was stable for at least 6 months before surgical intervention for the treatment of gynaecomastia. Those patients were included in the study. Patients were subjected to either circum-areolar or other long standard scar techniques in 2 equal groups. Patients were evaluated subjectively and objectively. Results: As for patient’s satisfaction, there was statistically significant higher satisfaction (p=0.039) among patients submitted to circum-areolar approach regarding the overall chest contour (80% vs 50%) and nipple-areola complex aesthetics (90% vs 60%). Objective assessment showed better outcome for circum-areolar scar in cases of moderate skin laxity and minimal glandular tissue, while other long standard scars could be appropriate with patients having massive skin laxity and marked glandular atrophy. Conclusion: Circum-areolar skin reduction technique is an effective, safe, and promising approach in the management of gynaecomastia after massive weight loss, which is an accomplished advancement relative to other standard long scar techniques. Circum-areolar skin reduction technique is the best for the patients with moderate skin redundancy where it preserved glandular tissue and no presence of side or back rolls. While, long scar techniques are favorable in patients with severe skin redundancy and atrophied glandular tissue with side or back rolls.

Comparative Study between Circum-areolar Skin Reduction and Standard Long Scar Techniques for Treatment of Severe Degrees of Gynaecomastia after Massive Weight Loss

Background: Reshaping of the male chest following massive weight loss is challenging and there are many techniques for its management. Aim: This study was to compare circum-areolar skin reduction for the treatment of severe gynaecomastia in massive weight loss patients with other standard long scar techniques. Patients and methods: Patients with massive weight loss whom their redundant and ptosed breast and patients whom their weight was stable for at least 6 months before surgical intervention for the treatment of gynaecomastia. Those patients were included in the study. Patients were subjected to either circum-areolar or other long standard scar techniques in 2 equal groups. Patients were evaluated subjectively and objectively. Results: As for patient’s satisfaction, there was statistically significant higher satisfaction (p=0.039) among patients submitted to circum-areolar approach regarding the overall chest contour (80% vs 50%) and nipple-areola complex aesthetics (90% vs 60%). Objective assessment showed better outcome for circum-areolar scar in cases of moderate skin laxity and minimal glandular tissue, while other long standard scars could be appropriate with patients having massive skin laxity and marked glandular atrophy. Conclusion: Circum-areolar skin reduction technique is an effective, safe, and promising approach in the management of gynaecomastia after massive weight loss, which is an accomplished advancement relative to other standard long scar techniques. Circum-areolar skin reduction technique is the best for the patients with moderate skin redundancy where it preserved glandular tissue and no presence of side or back rolls. While, long scar techniques are favorable in patients with severe skin redundancy and atrophied glandular tissue with side or back rolls.

A Randomized, Split-Face, Evaluator-Blind Clinical Trial Comparing Monopolar Radiofrequency Versus Microfocused Ultrasound With Visualization for Lifting and Tightening of the Face and Upper Neck.

Over the past decade, 2 major modalities for noninvasive skin tightening have emerged: monopolar capacitive-coupled radiofrequency (MRF) and microfocused ultrasound with visualization (MFU-V). Up to date, no comparative clinical trials have been performed. To compare the efficacy and safety of MRF versus MFU-V for the lifting and tightening of the face and neck. Twenty subjects with mild to moderate skin laxity received MFU-V over one-side of the face and MRF over the other side of the face at the same time. Subjects were followed for 6 months. Both MRF and MFU-V led to a decrease in the Fasil Face and Neck Laxity Grading Scale (FLR). These differences became significant at Day 30 and remained significantly improved through Days 90 and 180 in both groups. There was no statistically significant difference in the FLR Scale between MRF-treated and MFU-V-treated sides. Subjects' Global Aesthetic Improvement Scale showed improvement at Day 30, 90, and 180. Both MRF and MFU-V led to significant improvement in face and neck laxity. There were no statistical differences between MRF and MFU-V in standardized investigator measures of face and neck laxity, patient satisfaction, and adverse events.

Quantitative evaluation of skin shrinkage associated with non-invasive skin tightening: a simple method for reproducible linear measurement using microtattoos.

Non-invasive skin-tightening devices can induce thermal denaturation and skin shrinkage via externally applied radiofrequency emissions or high-frequency ultrasound. Therefore, the purpose of this study is to develop and test a method for measurement of skin reduction associated with application of such energy devices. Twenty-five healthy participants with mild to moderate skin laxity of the arms were enrolled. Pinpoint microtattoos were placed at each of the treatment sites to delineate two 6 × 12cm rectangles per subject. A non-stretchable filament, tape and marking pen apparatus was used to measure the size of each rectangle before treatment and at follow-up visit by two blinded investigators. After randomization, one side received a single pass with a radiofrequency device (6.78MHz), while the contralateral side received multiple passes. Participants underwent two treatment sessions to each side 2weeks apart, and returned for follow-up 4weeks after the second treatment. Length and area measurement were analyzed to assess precision and accuracy of measurements and to compare efficacy of treatment between pre- and post-treatment. Concordance correlation coefficients (CCC) demonstrated substantial inter-investigator reliability and precision in length measurements (CCC, 0.94 to 0.98 in pre-treatment; 0.95 to 0.98 in post-treatment). Measurements at the 6-week post-treatment follow-up demonstrated a statistically significant skin reduction in all six of the measured parameters. A simple skin measurement method requiring minimal instrumentation can quantitatively evaluate skin shrinkage associated with non-invasive skin-tightening devices.

Liposuction-Assisted Short-Scar Brachioplasty: Technical Highlights.

Upper arm contouring is based on the location and amount of excess skin and fat. The short-scar brachioplasty addresses minimal to moderate skin laxity and lipodystrophy in the proximal arm in patients with appropriate skin tone and quality. This article highlights technical refinements of the senior author's (R.J.R.) approach to short-scar medial liposuction-assisted brachioplasty to maximize results and minimize incision length. To highlight this simple and safe approach with high patient/surgeon satisfaction, the authors discuss the following in this Video Plus article: patient examination, preoperative assessment, surgical pearls, and postoperative outcomes.

Fractional high intensity focused radiofrequency in the treatment of mild to Moderate laxity of the lower face and neck: A pilot study

The aging process is commonly associated with skin laxity in the lower face and neck. Conventional surgery can correct this at least to some extent, but is invasive. Fractional high-intensity focused radiofrequency delivered to the dermis with insulated microneedles has recently attracted attention in facial rejuvenation. The present pilot study was designed to assess the efficacy of HiFR for skin laxity of the lower face and neck. Thirty-three patients (7 males, 26 females, age range 37-74 years) with mild to moderate skin laxity of the lower face/neck participated in the study. Three treatments were given at monthly intervals with protocols developed by the authors, three passes per session, at decreasing dermal depths for each pass. Histologic assessment of skin immediately after treatment was performed to identify the site and area of damage in the dermis. Clinical digital photography was taken at baseline and at 6 months after the final treatment session, based on which standardized computer measurement of improvement in the gnathion and cervicomental angles was the primary objective evaluation. A global assessment of improvement was graded by blinded assessors based on the photography. A telephone survey of patient satisfaction was performed at 12 months post-treatment. A significant post-treatment decrease in the cervicomental and gnathion angles was seen of 28.5° and 16.6°, respectively (P < 0.0001 for both). Histology immediately post-treatment showed a clear demarcated and roughly oval area of coagulation associated with the tip of the needle, confined to the dermis and not involving the epidermis. In the global assessment 81.8% of the patients achieved moderate or higher results, and 87% of patients were very satisfied or better. Downtime was minimal, lasting 3-4 days, and no persistent adverse events were recorded. Fractional HiFR proved safe and effective in the treatment of neck laxity in a large age range of patients, including the elderly. Lasers Surg. Med. 48:461-470, 2016. © 2016 Wiley Periodicals, Inc.

Randomized, Blinded Split Abdomen Study Evaluating Skin Shrinkage and Skin Tightening in Laser-Assisted Liposuction Versus Liposuction Control

Laser-assisted liposuction has shown great potential in facilitating fat removal, improving patient recovery time, and decreasing postoperative side effects. Clinical experience has indicated superior skin tightening after laser-assisted liposuction than with liposuction alone. The aim of the present study was to obtain quantitative, objective data for comparing tissue shrinkage and skin tightening achieved by laser-assisted liposuction versus liposuction alone. Ten female subjects from the author's private practice with unwanted abdominal adiposity and mild to moderate skin laxity were enrolled. On the abdominal skin of each patient, the corners of four rectangular regions (approximately 5 × 5 cm each) were tattooed with India ink and randomly assigned to treatment with laser-assisted liposuction (Smartly MPX laser, Cynosure, Inc., Westford, Massachusetts) or with liposuction alone. The laser system permits individual as well as sequential emission of 1064-nm and 1320-nm wavelengths. Skin shrinkage was quantified by calculating the changes in surface area of the regions. Skin tightening was quantified by changes in the skin stiffness index measured in the treated regions. One month and three months after treatment, the mean skin shrinkage ratios were significantly higher on the laser-treated side than on the suction side. One month after treatment with or without laser, the mean skin stiffness and skin tightening showed no statistically significant difference from baseline. Three months after treatment, the mean skin stiffness and skin tightening were significantly higher on the laser-treated side. Laser-assisted liposuction has a statistically significant effect on skin shrinkage and tightening of the skin in the abdominal area when compared to liposuction alone.

Cutaneous remodeling and photorejuvenation using radiofrequency devices

Radio frequency (RF) is electromagnetic radiation in the frequency range of 3-300GHz. The primary effects of RF energy on living tissue are considered to be thermal. The goal of the new devices based on these frequency ranges is to heat specific layers of the skin. The directed use of RF can induce dermal heating and cause collagen degeneration. Wound healing mechanisms promote the remodeling of collagen and wound contraction, which ultimately clinically enhances the appearance of mild to moderate skin laxity. Preliminary studies have reported efficacy in the treatment of laxity that involves the periorbital area and jowls. Because RF energy is not dependent on specific chromophore interaction, epidermal melanin is not at risk of destruction and treatment of all skin types is possible. As such, radiofrequency-based systems have been used successfully for nonablative skin rejuvenation, atrophic scar revision and treatment of unwanted hair, vascular lesions and inflammatory acne. The use of RF is becoming more popular, although a misunderstanding exists regarding the mechanisms and limitations of its actions. This concise review serves as an introduction and guide to many aspects of RF in the non ablative rejuvenation of skin.

A Classification System for Facial Fat Atrophy

Introduction: With aging, senescent fat atrophy occurs, with progressive degenerative changes in elastin and collagen in conjunction with marked bony resorption. The resultant effect is a noticeable deflation of the volume and contour of the face over time. We present here a study of facial fat atrophy in an attempt to develop a useful and transferable classification system for each type of identifiable area of noted volume loss. Materials and Methods: Three groups of patients (group I, 9 patients aged 10–30 years; group II, 8 patients aged 31–45 years; and group III, 9 patients aged 46–70 years) were evaluated by computed tomography head scans using standard radiologic cuts measuring 4 distinct areas of localized facial fat deposition: (1) periorbital, (2) buccal, (3) preauricular, and (4) temporal. The areas were measured on the right (R) and left (L) sides of the face, and an average value determined for each age group. Results: Buccal fat measurements for group I were (R) 23.84 mm, (L) 20.76 mm; for group II, (R) 27.56 mm, (L) 29.63 mm; and for group III, (R) 15.51 mm, (L) 14.34 mm. Group I exhibited a midrange of buccal fat in comparison to groups II and III, whereas group II showed the largest amount and group III the least. Preauricular fat measurements for group I were (R) 10.84 mm, (L) 10.00 mm; for group II, (R) 14.00 mm, (L) 13.82 mm; and for group III, (R) 6.86 mm, (L) 6.83 mm. Again, group I exhibited a midrange of preauricular fat in comparison to groups II and III, whereas group II showed the largest amount and group III the least. Temporal fat measurements for group I were (R) 12.04 mm, (L) 11.76 mm; for group II, (R) 18.86 mm, (L) 19.68 mm; and for group III, (R) 15.67 mm, (L) 16.63 mm. In this area, group I had the smallest amount of temporal fat, whereas group II had the largest amount, and group III showed a decline from the amount noted in group II. Periorbital fat measurements for group I were (R) 6.22 mm, (L) 5.72 mm; for group II, (R) 6.31 mm, (L) 7.21 mm; and for group III, (R) 7.33 mm, (L) 7.61 mm. In this instance, group I had the least amount of fat noted infraorbitally, with group II midrange, and group III had the most because of pseudoherniation of orbital fat. Discussion: The data collected in this paper display for each area of localized facial fat—except the periorbital area, which reflects the pseudoherniation of orbital fat contents—a progressive increase in localized facial fat deposits from group I to group II, with a subsequent decrease in group III in each area, consistent with senescent facial fat atrophy. Four types of facial fat atrophy classifications are thus described: type I, with fat atrophy limited to 1 area, minimal skin laxity, and minimal bony resorption; type II, with fat atrophy limited to 2 areas, mild skin laxity, and mild bony resorption; type III, with fat atrophy limited to 3 areas, moderate skin laxity, and moderate bony resorption; and type IV, with fat atrophy in all 4 areas, severe skin laxity, and severe bony resorption. Conclusion: Facial fat atrophy occurs progressively with aging in conjunction with loss of skin elasticity, collagen degradation of the skin, and bony resorption of the facial skeleton. This results in a progressive deflation of the face with obvious volume loss and subsequent skin redundancy. This classification system attempts to organize and categorize this occurrence.

Botulinum A exotoxin for the management of platysma bands.

Injections of botulinum A exotoxin are successfully used to treat neuromuscular disorders and to improve hyperkinetic muscles and dynamic rhytids of the upper face. Using these principles, we extended its use to the treatment of the aging neck (hypertrophic platysma muscle bands). A classification system (I to IV) based on horizontal neck rhytids, platysma bands, and skin laxity was devised to categorize the degree of deformity and serve as a guideline for suggested dosages of botulinum. The results correlated with the degree of age-related neck degeneration. Type II (mild horizontal neck rhytids; thin, mild platysma muscle flaccidity; and mild skin laxity) and III (moderate horizontal neck rhytids; thick, moderate platysma muscle flaccidity; and moderate skin laxity) patients were the most satisfied, followed closely by types I and IV. A total of 1500 patients were treated by three independent practices. The majority of them achieved good-to-excellent results, as evaluated by both the physician and patient. The degree of muscle flaccidity and hypertrophy were the factors that most influenced success rates, not the anatomic variations in muscle configuration.